How many planets are there?

Eight planets, and three dwarf planets (for now).

Pluto was officially demoted to "dwarf planet" status
on August 24th by the International Astronomical Union, as
it does not meet all three criteria for being
considered a planet: it must orbit the Sun, it must be
big enough for gravity to squash it into a round ball,
and it must have cleared other things out of the way
in its orbital neighborhood.

Dwarf planets only need to meet the first two criteria.

Poor pluto.

Fathers of Newborns

It wouldn't be fair or complete to write about mothers of newborns and leave out the fathers.

The difference between the first time fathers and the old hands is usually very striking. With the first child, the father looks in complete wonder at his small bundle of baby that he helped create. The reaction to the second, third, or fourth varies, but for the first child he just stares in ever-increasing exhausted wonder.

"I can't take my eyes off of her," says the father of a particularly beautiful little girl. He is black and his wife is a serene breath-takingly beautiful woman he met in Japan while teaching English over there. I learn to say "cute" (k-a-wai) and "beautiful" (uruwashii) in Japanese. I tell them their baby is beautiful, the dad is surprised, "Really?" "Yeah. Not all babies look alike. And she is beautiful." "But she looks like the babies I have seen on TV." "Exactally. They only put the beautiful babies on TV." "Oh." And he goes back to staring at his beautiful daughter.

"I was there for the whole thing!" this from an enthusiastic and involved 19 year old Hispanic father who explains that he was there for all the prenatal visits and the delivery and cut the cord. He hovers over his daughter, carefully and proficiently wrapping her up when we are finished examining. So proud.

One of the jobs I have been giving to the Dads is to install the base of the carseat at some point while their wife and baby are sleeping. Sometimes it is trickier and more difficult than it seems it should be. And it can take a while if it's your first time doing it. I even vaugely remember reading somewhere that 90% of them are installed incorrectly. So they have to pay particular attention to the manual and the details of the installation.

"I am so tired now that I can sleep on anything," says one of the Indian dads who could barely sleep the first night in the hospital due to the discomfort of the fold out squeaky cot in the hospital room. He has looked progressively more tired each morning. His son has exceptionally long toes and we ask who's toes those are. "If they're big, they're mine," he admits with a sleepy smile. As the attending is doing the exam on the baby, dad asks me how to open the new pill packaging. It's one of those tear apart then tear up the inner corner ones. I tell him he needs to grow fingernails to get it open..."or just have your son do it with their toes." Fortunately, in their sleep deprived state, they still think this is funny.

Then the fathers with their later children become either confidently proud, supportive, and attentive or distant and removed. Fortunately much more of the former than the latter.

"Sure, I remember how to burrito wrap [aka swaddle the baby]."

"When can she come home to take care of the other kids? I have to get back to work."

Then one of my favorites, again a first time dad, though, with his little girl. We try to put the mom and baby "skin to skin" right after birth so the baby can get some of the colostrum before she becomes very tired for the next 24 hours. Baby has only the diaper on and is inside mom's gown against her bare chest where she can hear her heart beat. It is very soothing for the baby and great bonding for the mom. The fun thing is, is that dads can do this too. No milk, of course, but they can still warm and comfort the little one right up against their chest.

It is fun to tell them this and then demonstrate it for the first time. He doesn't even have to take off his t-shirt. We usually just pull out the collar a little and slide the baby in. She'll stop crying immediately. And dad gets this amazed look on face as he holds her gingerly in his shirt.

So I did this with one of the Asian fathers. His t-shirt collar was too tight so we came up from the tummy part of it and popped his little girl's head out of the collar nestled right by his neck. He looked a little bowled over and shocked and very pleased.

"What do you think?" I ask.

"I like it," he looks at the warm little body that he helped create curled up contentedly on his chest, "but I'm hot."

She'll Carry his Heart

I knew an older couple who epitomized loving each other. They were thoughtful and kind and warm and giving and caring and open and loving, with each other and with those around them.

I met them when I was in high school. I loved them instantly. And I think they saw in me at least part of the children they were never able to have together. Throughout all my learning and my moves we always kept in touch. I'd send letters, they'd write back as unit. They were always together in my mind, and in reality. Sometmes I'd see them at the gym when I visited my family for vacations from school or work.

Together they built a house. Together they built a garden. Together they created a years full of love.

I wanted to be like them from the moment I met them. I wanted to have a love like theirs. A life full of it.

A month ago he died unexpectedly--cancer everywhere. He was gone in six weeks.

I just found out the other day and it has been on my mind a lot. He has been on my mind a lot. As has she. They were such a pair, I can't picture one without the other. Together they helped define each other.

My mom talked with her today for a long time. "Sometimes you just go on because you have to." I suppose you do.

She'll carry his heart (she'll carry it in her heart).

I carry your heart

i carry your heart with me
(i carry it inmy heart)
i am never without it
(anywhere i go you go, my dear;
and whatever is done by only me is your doing, my darling)

i fear no fate
(for you are my fate, my sweet)
i want no world
(for beautiful you are my world, my true)
and it's you are whatever a moon has always meant
and whatever a sun will always sing is you

here is the deepest secret nobody knows
(here is the root of the root and the bud of the bud
and the sky of the sky of a tree called life; which grows
higher than soul can hope or mind can hide)
and this is the wonder that's keeping the stars apart

i carry your heart
(i carry it in my heart)

e.e. cummings

Azucar

We have a lot of Spanish-speaking families who deliver in the nursery. In Spanish, "azucar," means "sugar."

One of the mother's had had no prenatal care. Not a single visit. None of the usual screens. I'm not even sure she took pretnal vitamins. Her baby came out okay, but he had a very low blood glucose of 15 on our first check. The nurse practitioner fed him and rechecked and it was only up to 35--still pretty low. We weren't sure what to believe since he was pretty asymtomatic and sometimes the tests are wrong.

I suggested that we check mom's blood glucse since she may have had gestational diabetes which would cause the baby to hypoglycemic soon after birth. It's something that would have been picked up during the prenatal care, but hadn't gone. The nurse practitioner had already gently scolded her about this so she was sort of in a huff about it to begin with.

She was in even more of a huff after we checked her blood sugar and she sat there indignant holding the bandaid on her punctured finger, glaring around angrily.

By this time the father of the baby had come in to be with them both and he agreed with the medical team. I guess he'd wanted her to get care all along but she thought it wasn't necessary and was too much of a bother. "I told you so," was the look on his face as they sat about three feet apart and listened to us explain that the baby's "azucar" was low and that we needed to check hers. Her's was normal so she was even more huffy.

At some point during this discussion, she decides that she has had enough and thinks of a way to blame this whole charade on someone else. She points to her husband, "Check his sugar, too. It is probably his fault."

"That's impossible," we explain to her, "we don't need to check his sugar. He didn't carry the baby!" She is still upset, but her son turns out to be fine. He glucose rises approriately with the next feed.

Check his sugar. We try not to giggle about it too much. It's funnier when you see the nurse practitioner tell it...but maybe it's a little funny here, too.

Placentas

In the Newborn Nursery this past week I took care of a family with twins. They parents are from a country in Africa and through the week the mom (who is my age and in her last year of undergrad) and I really bonded and learned a ton about each other.

The first morning (those first 24 hours the babies sleep a lot) I went in and she was awake and perky and doing great. She'd delivered one vaginally and the other they had to do via c-section. So not only did she have twins to take care of (her first) but she was also recovering from surgery and had lost a lot of blood post op so was anemic.

Plus these twins were the first grandchildren on both her and her husband's side. And the first children of any of their friends or relatives in this country. Fortunately, the father's mother was in town to help and meet them, but still, mom had to be overwhelmed.

By the second day the babies have usually passed their meconium and their bowels are moving and they are hungry! And mom usually only has colostrum which does a lot for their immune status but little to fill up their bellies and curb their hunger.

That morning I went in to find her with a baby on each side of her in bed trying to nurse one while holding the other. The cousin who was supposed to be helping her was sleeping soundly in the less than comfortable bed at her side. I examined the babies and helped change the diapers as we talked about some of the newborn care tips. We started co-bedding the twins (putting them in the same crib) and they really liked being close to each other. They'd reach out their little hands or suck on each other's faces.

They had a name for the boy from the beginning, but still were struggling with the girl's name. The whole extended family was involved in the controversy and nothing was getting settled. Finally the family just told them to pick one that they liked. I talked with the mom about it and she wanted a name that had meaning. We didn't have any name books in the nursery so I looked up some on line and wrote out a couple pages of names with meanings for her.

The following day, the maternal hormones finally got the better of her and she broke down crying at one point. Post-partum "baby blues" last about three weeks before the woman's hormones calm back down. This is different than post-partum depression which usually presents later and can last up to six months. She had been super strong, and still was, but she was feeling like she wasn't a good mom and couldn't nurse well or do anything right.

On the first day that I had met them my attending said that sometimes families from Africa have a tradition of burying the placenta at the place where they were born or the place of their roots so that they will always remember where home is. I asked the mom about this when I saw her the next day. She wasn't sure about it, but said that her mom had her and her six siblings dried up umbilical cords though she wasn't sure why.

When grandma got off the phone next to her, we asked her about the traditions. She said it was true about the placenta. That many familiy's buried it so they would always have a home to come back to. And that the umbilical cord was used whenever the child had a cut or a fever to help him or her recover. She said that after drawing a circle around the cut with the cord that it would be gone in two days. Or with a fever, just rubbing the dried cord on the temples would make the fever go away the next day. Interesting.

Later in they day on the third day, I visited them and mom was sleeping, so I looked at the babies and she woke up a little. She said she'd named the girl at last. "What is it?!?" I was excited that she would have a name at last. "It's on a paper there." It was like she wanted me to find it to open the present. I didn't find the paper so just ended up just telling me. It was one of the names that I'd found for them! Or a permutation of one anyway. And it meant "pure."

By the fourth day, her milk was coming in well and she was doing better with breastfeeding, but the babies were young and still loosing a little more weight than we liked. We decided to keep them one more day and hope that they started to grow a bit more.

That gave me a chance to see if they wanted to have their placenta. Sounds gross, I know, but they are actually intersting. In Neonatal Pathology a couple days before we'd looked at pictures of her plactenta. Her twins here diamnionic-dichorionic but the boy had muce more than his share of the placenta, so their had discordant growth of 15%, that is, he was 15% bigger than her when they were born. You can see on the picture which half is smaller and has the cord insertion more off to the side. In fact the reason they'd decided to deliver them early was that the girl had stopped growing a couple weeks before delivery when they looked by ultrasounds (Intrauterine growth restriction = IUGR).

So, I got the bright idea to ask them if they wanted their placenta to bury or take back to Africa, even though I'm not sure you can take such things on a plane. It would have to be refrigerated for sure. Mom was a little grossed out, but wanted to see it at least.

Therein began my adventure of tracking down the placenta.

Fortunately I'd worked in the NICU already so I had connections there. One attending in particular was really into placentas so I got in touch with him and figured out where it might be kept if we still had it. In talking to him he also informed me that it wasn't the first time and that lots of families (well not lots, but some families) will take them and bury them where they plant a tree. Some "hippies from Northern California" even cook them and eat them. "I have recipies," he tells me. "Uh, that's okay," I decline and make a face, glad that I'm talking to him on the phone instead of in person.

Anyway, apparently there is a "placenta frigde" across from the OB area. I get one of the nurses to let me into the locked room. I'd been smart enough to get gloves for both of us before we went in, which turned out to be a very good thing. The fridge was one of those glass-doored slide open ones which labeled shelves full of styrofoam drinking containers containing each placenta. The lids were clear and you could sort of see the blood inside. They were all labeled with the baby's name. The ones that had been looked at already were messy on the outside, too. Gross...and smelly...like raw meat.

The nurse is nice enough to help me as we sort through all close to 100 placentas. We're taking them out and stacking them and reaching toward the back looking for the right one. "I'm elbow deep in placentas," I think to myself at one point, "Never thought I'd be doing this, that's for sure." It is of course one of the last ones we check, but at least we find it.

The only bag we can find is a clear one so as I'm trapsing around the NICU seeing if we have lecture that afternoon everyone is looking at me funny. But not as funny as the nurses when I get back upstairs. "What is that?!" "A placenta." I sort of enjoy the grossed-out shock on their faces. He he.

I take it to the mom and she gets the same grossed out look on her face. "I'm not sure I even want it now," she says. Then she takes a big sigh like she's bracing herself and says, "Okay, I let's see it." But she's about to eat lunch and I think it might not be great timing, so I offer to bring it back later. She looks relieved and agrees.

Then I have to find a refridgerator in which to keep it in the meantime. Fortunately, after more shocked nurse faces, I find that there is another placenta fridge at the other end of the nursery. The things you find out!

As I'm telling my attending about it over her lunch of a bologna sandwitch, she asks where I'd stored it. "In there," and I point quickly and casually to our office lunch fridge. She stops chewing and gets a little pale as her eyes dart to the fridge from which she'd just retrieved her lunch. I can't keep her in suspense long though and I tell her I'm only kidding.

Turns out that even after the mom's lunch she didn't want the placenta. They were too far from home (Africa) to really have anywhere meaningful to bury it anyway. They were only renting an apartment in town so it wouldn't work here either.

Oh, well, I tried. (And yes, that really is her placenta...in the flesh.)

Mothers of Newborns

It is strange to see the contrast of different mothers and how they act with their newborn baby. Fortunatly, my patients have all had loving adoring mothers. Even when their baby (or babies in the case of one family) go through the "feeding frenzy" (when baby's gut finally starts moving and mom's milk comes in and the baby wants to eat ALL the time) on days two and three of life, they look exhaustedly patient and happy.

But today I went into a room with my co-intern's patient--a cocaine-addicted mom with a tox screen positive at pregnancy, no prenatal care, etc. She had the baby in bed with her when we woke her up. As we were taking the baby to examine her, she kept calling her, "Hey Fatty. Hey," and not in much of a warm loving way. We told her the baby had a few problems, like a heart murmer that may or may not be serious, and the mother's response was, "Yeah, I thought she'd be alright, for as much as I ate." We all try not to look shocked or judging, and think to ourselves, "What about all the crack you 'ate'"? Plus, when the social worker asked her if she had diapers ("no"), carseat, ("no"), crib ("no"), etc., she finally said, "Why don't you tell me what you do have. Turns out she had nothing to prepare for her new baby. Maybe because she knew there was no way we'd let the baby go home with her. Which we, along with Child Protective Services, won't.

It was a relief to visit my other mothers, even the HIV infected mother who thought and thought about having her baby and finally decided to have her and love her and take the very small risk of transmission. (No baby seroconverted here or in Cincinnati in the last 10 years when mom has good prenatal care, AZT during delivery, and doesn't breast feed.) But we won't know for completely certain until the baby is 18 months old. Their baby (dad there, too, always nice) cried all night but when I woke them up to ask how she was this morning (mean, I know, hospitals are not good places for rest) she groggily arose and again looked adoringly at her baby and waited anxiously for me to finish my exam to make sure everything was still okay. She had a very common newborn rash called erythema toxicum that looks sort of like migrating bug bites with a little white dot in the middle. It occurs in about 70-80% of newborns and is completely harmless and goes away in a week or two. "Your baby is perfect." The parents who love their babies completely love to hear that and hang on your every word. "Your baby is perfect." It is full of promise and relief and joy. "Your baby is perfect."

I'm learning a ton in these first few days of the rotation:

1. Erythema toxicum: The rash mentioned above. New theory is that it is the result of mom's developing white blood cells that cross the placenta and get into the baby's skin and the redness reaction is the baby's body trying to get rid of them by a collection of eosinophils (the body's cells that usually respond in allergic conditions).

2. Meth/Cocaine v. Narcatic IUDE (intrauterine drug exposure): Amphetamine babies do better in the newborn period because withdrawal from heroin is awful (the babies are fussy and agitated and uncomfortable, the best treatment is actually mother's milk which will have some of the narcotic in it if she is in a tapering treatment program--the baby gets tapered with her through the milk). Anyway, the methadone babies have this awful pained cry until the drug is weaned from their system. The cocaine or crystal meth babies are jittery for a little while at first, but then do okay in the short term. In the long-term, they have many more developmental delays and problems with learning and behavior, even microcephaly (small head) or other physical deformities.

3. Soy-based formulas: If you must feed your baby formula, no babies should have soy-based formula. There was concern that the milk-based formula's caused more allergies but if that is a problem it is better to just go straight to the elemental formulas like Progestemil. Soy doesn't have the right protiens for a baby's optimal growth.

4. Crib next to bed: For the first six months of life, it is good to keep the baby's bassinet right next to the parents' bed. This prevents the risk of rolling over on them with co-bedding, but it reduces the risk of SIDS (sudden infant death syndrome), probably because of the hightened awareness and stimulation from the close proximity.

5. Circumcision: About 80% of parents choose to circumsize their newborn boys. Circumcision actually started thousands of years ago in Jewish cultures (I think) as a way to desensitize the penis and prevent boys from masterbating and succombing to sexual pleasures as readily (not sure that works). Circumsicions are not at all fun to watch or assist. If more parents could see it, I don't think they'd choose it so carelessly. And insurance companies don't pay for it so they cost around $250.

6. Head shaping: In 1992, when pediatricians began recommending the "Back to Sleep" position, the incidence of SIDS in this country dropped dramatically. But there has been one problem that has developed. When babies sleep on their back all the time, it is usually the back of their head that is flat on the mattress. Because baby's skull bones are still fusing and growing, their heads can become misshapen. To prevent this, we're now encouraging parents to adjust their baby's head when they put them to sleep. Alternate sides of the head that they rest on. Left, right, back of head alternating.

7. Neck stiffness: Since babies are all crunched up inutero, about 20% will be born with some tight muscles on one side of his or her neck. This is best tested by gently stretching their ear to their shoulder (instead of the more standard chin to shoulder twist which can miss a lot). If it's mild, like most is, it can be treated simply by putting the baby to sleep preferentially so that they look to the opposite direction and stretch out that side of their neck. If more severe, you can get some neck stretching exercises from your pediatrician.

8. Lacrimal duct cyst: I guess about 20% of lacrimal ducts (the duct that drains your tears into your mouth) are stenotic (small). We had one baby yesterday who had a pretty small duct and got infected with E. Coli in his eye because of it. The opthamolgists came to treat him and it was much more brutal than any of us expected. They were good at it and it looked pretty straight-forward, but it was a pretty forceful POP and forcing open of the duct with this thing that looked like a fancy stretched out paper clip. Our attending had never seen one and she almost had to sit down afterwards.

9. Ear tag: Little nubbin of extra skin off the ear. Very common and runs in families. One of my patients has one. We treated it by just tying it off really tightly with a string to block off the blood flow and let it die a natural death and fall off by itself in four or five days. The ENT docs don't always like this because it leaves a very small bump behind, but the alternative is a bigger surgery with general anesthesia with them. Most parents choose the string. Strangely, this is also how my brother castrates his baby goats--except with a rubberband instead of a string.


I took a ridiculously long nap this afternoon after being emotionally exhausted for reasons entirely unrelated to work, so now I'm wide awake. Great. I'll read for a little while.

I love holding the babies. It makes me want my own. Guess I'm about that age anyway.

I Need Some Less Colorful Stories

The other weekend at B's wedding shower, we're all sitting around and they are asking me about crazy stuff I've seen at the hospital. The only ones I can think of are borderline scandalous. Stuff that is so strange you can't even make it up. How does it even cross anyone's mind to do these things? At what point does the line of normalcy just utterly disappear? I know my line is being pushed. Once you go past normal, maybe there's no going back.


Some of the best stories tend to come from the Obsetrics realm. When it comes to sex and babies and mostly sex people do ALL sorts of strange strange things.

During our third year rotation, we are asked to check the dilation of the cervix when women are in labor to see how close they are to delivering. So one of my fellow third year med students has to do this on a very overweight woman. And he's literally up past his elbow getting past the extra leg fat. As he's there, he wonders, "How on earth did this woman get pregnant? Just the mechanics of it are infathomable." So he does what I would not have had the gall to do...and he asks her. She non-chalantly explains that she and her significant other used a broomstick. A broomstick. To hold her thighs apart while they made love. A broomstick!? I think I'd sooner go on a diet.


One caucasion couple had a baby who came out looking strangely dark for their skin tones. Dad is over looking at the newborn and asks the nurse if he is suppposed to be that dark. The nurse sort of evades the question and the whole staff becomes a little uncomfortable. Dad isn't mad at Mom, though. As it turned out in their case, about 40 weeks before, as birthday present to one of them, the dad's best friend (who is African American) slept with the mom while dad watched. Wierd to begin with (and even more to end with, poor child), but at least use protection if you're going to do stuff like that.


Then there was the guy who came into the ER with a peanut up his penis, "just to see if it would fit."


There's an urban legend story of a guy who got a hold of a prescription pad and took it to the pharmacy with a self-written script reading "Mo-feen, 1 pound." That didn't get filled.


There's a bittersweet story of my own from last month: A sixteen year old was riding a motorcycle for the first time without a helmet and crashed with severe brain death. The family decided to donate his organs. As we walked around the ward, we had many new patients in for trasplants. "This one is getting a kidney." "The other kidney goes to the kid across the hall." "Someone upstairs is getting the heart and lungs." The end for one and a new lease on life for others. The emotions of transplant confuse me. I still have trouble reconciling the death of one leading to the life of many. If I were in that situation, I'd want my organs donated in a second. I guess when there is no hope for using them yourself, in some way you can live on and help others, even after death. And what better way to leave this world, I suppose.

Newborn Nursery

When I first started in the Newborn Nursery I felt totally inadequate. I've been around sick kids, sick adults, tired interns, etc. Everyone needing fixing in some way.

With the newborn nursery the babies are (mostly) perfect and the parents are tired but have this excited wondering glow about them. It is a moment that does not need fixing or meddling or doctoring. They are moments of the most pure wonder and love.

And yet, there I am. Trying to "fix" this? "Seriously," I thought on the first day, "there's nothing I can possibly do to help this situation. How do you improve on perfection?"

By the second day I'd semi-sorted it out. I was there not to add to (or subtract from, mind you) the emotion of the moments, but I could add to the logistics of the new little life now in permenant tow.

1. "Back to Sleep" Boca arriba--head up. Put your baby to sleep on his or her back to help reduce the chance of Sudden Infant Death Syndrome (SIDS). Do not have extra blankets or pillows or that cute stuffed bear from Aunt Margaret adorning the crib. A single blanket not by the face is appropriate.

2. Keep in mind, however that on her back is not a position of comfort for your newborn. It makes them feel like they are falling. So when soothing them, they prefer to be on their side usually; you can pat them or make soothing noises to calm her down.

3. "Fourth Trimester" I know, it literally makes no sense, but teleologically this one does make some sense. As humans developed, their brains continued to get proportionally bigger in comparison with their bodies. And therefore, gestations had to become shorter or else mom was never going to be able to push that big head out of her small (but thankfully stretchy) opening. So there is the concept of the "fourth trimester"--the idea that for the first two to three months of life, babies like to have their environment simulate the womb. Because, if their heads weren't so big, they'd still likely be in there. So your newborn will like things like:

• Being "burrito" wrapped snuggly in blankets that contain their limbs in flexed positions. It is not too tight if you can still comfortably fit two finger between the blanket and the baby. I've learned a couple burrito wrap methods. It's easier to have shown then to explain here, but maybe I'll try later with pictures if I get ambitious.
• White noise; quiet swishing like the blood circulating through the placenta and around the baby.
• This is also why they like to be on their side; more like the womb
• And other stuff that I will hopefully learn over the next three weeks. I guess there's a book called "Happiest Baby on the Block" that is good at explaining these sort of things.

4. Jaundice --many babies will have high bilirubin at their 24 hour of life check, usually not dangerously high, but we check just in case. Their livers don't process the bilirubin very effeciently yet so it gets high. With premies it doesn't peak until the fourth to fifth day of life. If it's high, we start "bili lights"--these really cool blue suntanning looking lights--or a "bili blanket." Babies who breast feed or are of certain ethnic backgrounds or have blood type incompatibilites or bruising during birth are at higher risk.

5. Breast Feeding--breast milk is BY FAR the best thing for your baby (except in rare cases when you have to take medicine that is not good for the baby or you are HIV positive). Breast milk, and I didn't really know this, is a dynamic substance that changes through the course of one nursing and changes from the first nursing to the later nursings. It imparts immunity and the perfect mix of enzymes and electrolytes and proteins to your growing baby. Remember, "breast is best." If you're having trouble breast feeding, lactation consultants are great. The nipple should fall into the baby's mouth comfortably. You can massage the upper breast to encourage the milk to come down. Milk will not fully "come in" for at least a couple days.

6. Weight loss--we expect babies to lose weight over the first few days of life. By one week of age they should be back up to their birth weight.

7. Car seats--be sure you know the proper way to strap them into your car. Your baby's shoulders should not be below the level of the top restraints. That is, the restraints need to insert into the seat either at or below the level of the baby's shoulders.

8. Cord Care--just leave it open to the air and let it dry out and fall off. Doctors used to recommend cleaning it with alcohol but that isn't really necessary and is one more discomort for your newborn. The cords will fall off on their own, so just let them.

9. Pediatrician--be sure to have a pediatrician picked out and then you can make your first post hospital check up appointment with him or her before you even go home from the hospital. Everyone will want to be sure you have good follow up care.

Etc. etc. I guess I'm not totally useless, even if everyone is happy and healthy.

Thunderstorm Rambling

The weather is perfect here. I mean perfect. Sixty-eight to 72 degrees year round. Lots of sun. Slight ocean breeze. Perfect.

And despite loving it and feeling refreshed by the ocean waves and the sun and the breeze, sometimes I want a thunderstorm.

Tonight I bought a thunderstorm on iTunes. $9.99. Ten dollars for a thunderstorm. I know it's not the same as the real thing, but it's the closest I'm going to get here in the land of perfect weather.

I'd been wanting a thunderstorm for a while. This ways I got the bonus "Rainshower," "Rolling Thunder," "Southern Swamp," etc. I can just play them on repeat and be in control of my audio weather whenever I need a good sky cry.

That along with my day off and some introspection got me thinking about my life. Always a bit of a dangerous undertaking, particularly for me for some reason...or maybe for everyone and no one really talks about it too much.

I remember when I was getting my letters of recommendation together for med school. One of my literature professors said it was the first letter of the sort that she'd written. She said it was a shame I wasn't going into literary reviews--that I was very imaginative and natural with it--but that I guess we needed doctors with those skills too. In the end, I knew that the writing was too constantly and consitently close to thinking about myself. It turned all of my thoughts inward and asked me to constantly question and evaluate and critique all human behavior and knowledge and desires.

In a way, medicine is similar, but it's much more turned outward. It of course touches and affects who you are, but it also has the "rules" of science and the ample social aspect to dilute the introspection and self-analysis that can get me so tied up into teleologic knots.

The thunderstorm wish got me thinking about how I seem to often want something different than that which I have. It snows, and I want the beach. It is sunny and I want a thunderstorm. He leaves me and I want him to stay. He stays and I want him to go. I'm not the only one--I know of at least a few others in my own family.
And maybe there are more closet wonderers out there.

Maybe they're all the INFPs of the world (Meyer Briggs)--idealists who can become disillusioned. It's a tough road. My dad is one, too. When he found out that I'd taken the test and was the same as him, his first response was, "Oh no! I'm sorry." Really.

It always seems to leave me thinking about how things could be better. Trying to change them. Then getting sometimes frusterated if they are not as good as I know they could be. Not only for myself, for the families at the hospital, for the patients in the wards, for the homeless people who sleep on the benches along the boardwalk, and for me, too.

I've always had fantasies about what my future would be like. In comparing my present to what I thought it would be, it's professionally better than I could have imagined. I love the career I've chosen. It opens so much opportunity for growth and change and help. It's a lot of work and stress, but I can handle that. In fact, I even seem to do better with more stimulation.

Personally, my life is not quite what I pictured. Instead of taking care of everyone else's babies, I thought I'd have one of my own by now. At least one. Or at least someone with whom I wanted to have children.

Many women doctors, by the nature of their career choice, don't have children until they are AMA ("Advanced Maternal Age" = 35). It's a trade-off that I'm not sure we all thought that much about when starting medical school.

Anyway, when I step back and look at the bigger pattern of my life, there is always that element of "the grass is greener."

I would be with someone nice and want the "rebel" man instead. I would be with him and then want him to treat me nicely like the first guy had. At what point does it come back to me just deciding what and who I want? At what point is it me deciding to be satisfied with the grass I have? "One bird in hand in worth two in the bush."

When do I decide to just accept situations for what they are instead of always trying to change them and improve them? And in the process, and by comparison with my vision of what it "should" be, becoming dissatisfied with the way that it actually is.

I get my sunny ocean surf, and what do I do? Buy a thunderstorm.

I Loved to Write

I would pour parts of my soul into it...

I miss that. I recently gave away my dinosaur of a computer (circa 1996) with all of my essays on it. I guess with parts of my soul in it. Not really, though. The thoughts are still with me. Everything else is just paper and words.

Or if you listen to James Blunt, "It's more than just words, it's just tears and rain."

I miss writing like that though. I don't know when else I'll be able to dedicate such time and energy to it. Those of you out there complaining about college work loads, take a few minutes to enjoy the fact that you get to learn...just learn.



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TRADIT CANON,PART1
Course Description
A survey of English Literature from Chaucer to Cowper. Two
papers; two memorizations; a midterm; and a final exam.

Evaluation
XXXXX did consistently excellent work in this course. Early on she
distinguished herself as an excellent interpreter in section
discussions, and her work throughout showed a sensitivity to verbal
detail and to interpretive issues, poetic and thematic, that was
admirable. Her papers had largeness of vision as she argued
positions boldly and imaginatively. Her exams were both fine
efforts, notable for her sharp, systematic observations; the final
was excellent--thoughtful, adventurous, exploratory, challenging.



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DANTE DIVINE COMEDY
Course Description
Students read Dante's Vita Nuova; the Inferno and the
Purgatorio of the Divine Comedy; selected lyrics from the
French and Italian courtly love tradition; selected books of
Virgil's Aeneid. Two papers (of 6 and of 8 pages) and a final
exam were required.



Evaluation
XXXXX did consistently excellent work in this course. She was a
regular participant in section and could always be relied upon to
raise provocative and challenging points. XXXXX's written work was
outstanding. Her first essay was a thoughtful, well-researched, and
well-argued discussion of different types of love in the Vita
Nuova and the Inferno. Equally successful was XXXXX's second
essay which performed a deconstructive reading of Cantos V and
XXXIII of the Inferno. Here, XXXXX asserted that a simple
mirroring (between love and hate; between Francesca and Ugolino) was
an overly simplified characterization of these seeming oppositions,
and that Dante required a more complex model that considered the
problematics of language more explicitly. XXXXX met regularly with
a group of other advanced students on her own time to further her
study of Dante, and she often consulted her teaching assistant for
suggestions about improving her already excellent work. XXXXX was
one of the most dedicated students in the section. Her excellent
final exam displayed her vast knowledge of the course material that
was evident in all of her work. Overall, an outstanding quarter's
work.


--------------------------------------------------------------------------------
TRAD CANON, PART II
Evaluation
Survey of canonical 19th and 20th century British Literature;
readings: British poetry from William Blake through Seamus Heaney,
Charles Dickens's Our Mutual Friend. Students were required to
form small groups (3-5 people) and meet on a weekly basis
throughout the quarter to read poetry that was assigned but not
discussed in detail in lecture and work on Our Mutual Friend.
Groups were required to prepare at least one presentation of a
monthly part of Our Mututal Friend. Students were also
required to memorize and recite two selections of poetry of at least
twenty lines, and attend two poetry readings. There were two paper
assignments (4-5 pages), a midterm and a final exam. Students were
expected to demonstrate an understanding of the distinguishing
characteristics of Romantic, Victorian, and 20th century poetry and
prose, and of the social, political, intellectual, and historical
events and issues that shaped the English canon.

She did fine close readings of Byron and Wordsworth; her discussion
in the first paper of what is "lost" in the translation to prose was
excellent, as well as the commentary on the use of "shorter lines"
in poetry.

Her midterms were very good, especially on the Brownings; her final
excellent, very well expressed and articulated, thorough, thoughtful
and sophisticated. She participated actively and thoughtfully in
class discussion; her group did some of the best presentations on
Dickens. The course engaged her personally and she responded with
excellent work.


--------------------------------------------------------------------------------
AGE OF JOHNSON
Evaluation
XXXXX's work in this course was outstanding. She attended every
class, made frequent contributions to class discussion, and prepared
no less than three drafts of her final paper. She showed a high
degree of familiarity with all of the material studied in the class:
one of her most striking qualities as a classroom participant, in
fact, was her ability to produce passages from the text to support
the more generalized comments of her colleagues. Her in-class
presentation on Samuel Johnson's The Vanity of Human Wishes was
carefully researched and clearly delivered. In the accompanying
short essay, she alternated well between outlining general themes
and providing astute close readings of passages from the text. The
paper's only drawback was its tendency to make use of critical
truisms about Johnson without interrogating their validity. In
response to this suggestion about her first paper, XXXXX wrote an
entire final paper devoted to exploring some of the critical
literature on the question of Johnson's relation to hope and
pessimism-a central theme in Johnson criticism. She used her
secondary sources extremely well, testing them against her own
readings of individual passages from Johnson's poetry and prose.
Successive drafts showed greater and greater strengths in terms of
thesis, organization, and use of textual evidence, and she ended up
with a convincing and nuanced argument that I found at least as
compelling as much of the criticism to which she was responding.
XXXXX is a gifted writer and an extremely hard worker, whose
willingness to respond to suggestions about her thinking and her
writing enables the sort of rapid improvement demonstrated in her
skills as a literary critic over the course of this quarter.

--------------------------------------------------------------------------------
STUDIES IN DICKENS
Course Description
This senior seminar focused on Dickens. We read several of his
works and discussed parts of Little Dorrit, commenting on
each other's presentations. Each student wrote a substantial
essay of at least 25 pages on an aspect of Dickens's fiction,
after handing in a preliminary prospectus, and critical
bibliography. Students participated actively in class discussion;
the materials of the course engaged them personally, and they
responded with thoughtful, accomplished work.

Evaluation
Her paper: "Ah, Love, Let Us Be True: Meaning-Making in Dickensian
England," was sophisticated, sustained and insightful.It articulated
central issues in Dickens and Victorian culture in analyzing the
issue of meaning-making. There was fine use of Wordsworth and
Arnold in providing important perspectives for Dickens, and there
was an exceptionally good.discussion of the theme of love and
idealism in the novels.It was well written, fine work. She did fine
work in this course.

--------------------------------------------------------------------------------
19TH C.ENGLSH NOVEL

Evaluation
XXXXX accomplished outstanding work in this course. Her first
paper was a successful and engaging analysis of hope and
friendship in William Makepeace Thackeray's Vanity Fair. In
this essay XXXXX convincingly argued that Thackeray's bleak novel
is not completely devoid of transcendental possibilities. Her
second paper, equally engaging as the first, was a highly
intelligent and careful Jungian analysis of opposing selves in
Bronte's Jane Eyre. Her third paper, perhaps the strongest of
them all, examined the inevitable sense of dissatisfaction that
accompanies Pip's expectations in Dickens's 1861 classic, Great
Expectations. For all three of these papers XXXXX submitted
carefully composed drafts and discussed possibilities for
improvement with the instructor long before the final due dates.
Her incorporation of the instructor's suggestions, along with her
own excellent sense of finish, transformed her papers into highly
polished pieces of writing. XXXXX's perfect attendance at lecture
and section demonstrated consistent engagement with course issues
and themes. Her perfect exam was a fine conclusion to a quarter of
exceptional work. In all, an inspirational performance.
--------------------------------------------------------------------------------

MILTON
Evaluation
XXXXX's work in this course was outstanding. This was her third
course taken with the same instructor, and in each case she has
demonstrated a similarly high degree of engagement, responsibility,
and maturity as a thinker and writer. XXXXX's tendency is to go
beyond the demands of any given assignment: in her presentation on
one of Milton's short poems, for instance, she included a glossary
of key words assembled using the OED. These glossaries subsequently
became a requirement for all presenters. In this presentation, and
in her first paper, XXXXX showed a very strong ability to locate
and analyze the central tensions of the poems under discussion.
Rather than staying away from particularly difficult moments in the
text-moments of confusion or lines that are difficult to
comprehend-XXXXX seems to be drawn to such moments. She chose to
submit a series of drafts for her final essay and to do considerable
outside research. Her reading list would have been ample for a paper
written for a graduate seminar. The paper, on the figure of the
author in Paradise Lost, combined astute textual analysis with a
sharp knowledge of the context of early modern authorship and
authority. Her paper was one of the two most polished and original
final papers in the class.

--------------------------------------------------------------------------------

SOUTH AFRICAN LIT
A survey of South African literature in English from
1948 to the present. In addition to a brief map assignment, students
wrote two short papers, a 6- to 8-page paper on Gordimer's July's
People, and a final examination.

Evaluation
XXXXX XXXXX was an outstanding student in this course. With
nearly perfect attendance at both lecture and section, XXXXX was a
frequent contributor to class discussions. XXXXX's writing for the
course was equally impressive, partly because she often turned in
rough drafts of her papers to the TA for feedback and produced
revisions of her papers when she wasn't satisfied with the result.
In her first paper, XXXXX argued that Can Themba's short story "The
Dube Train" is about the black population's complicity in their
oppression under apartheid and that the action of the story serves
as a call to action. This was a valid and sophisticated argument to
make and XXXXX's prose in this paper was fluid and concise.
XXXXX's second paper traced the symbol of the unicorn in Nadine
Gordimer's novel Burger's Daughter. XXXXX argued that the unicorn
represents various things, including but not limited to Rosa's
fantasy of remaining in Europe as well as hope in the resistance
movement. XXXXX's argument in this paper was intricate and
fascinating. In her final paper, XXXXX argued that in Zoe Wicomb's
You Can't Get Lost in Cape Town, the character Frieda (and Wicomb
herself) writes herself a place to exist within her own created
text. Again, XXXXX produced a well-argued and well-articulated
paper. Overall, XXXXX was an outstanding student whose work in the
course was truly exemplary.

INFP

INFP

The Idealist

You are creative with a great imagination, living in your own inner world.Open minded and accepting, you strive for harmony in your important relationships.It takes a long time for people to get to know you. You are hesitant to let people get close.But once you care for someone, you do everything you can to help them grow and develop.

You would make an excellent writer, psychologist, or artist.

What Should Have Been

Last overnight call for the next two months! Wow. I never thought I'd see the day. It was a good call, too. Steady enough to be interesting and slow enough to sneak in a siesta at 3 am.

Patients admitted last night:

1. Rule out sepsis--pretty standard protocol, cute little seven day old with fever and rash. Babies can't tell you where it hurts so you have to go on a treasure hunt looking for bacteria, end up usually not finding it and figuring that it's viral anyway but treating with antibiotics in the meantime until your cultures come back negative.

2. Acute Life Threatening Event (ALTE)--another peanut. 16 day old former 35 wk premie with super awful reflux and super anxious parents. Also with failure to thrive; he hasn't even regained his birth weight and his little skin sags all over him like it knows it's supposed to be covering a bigger body.

3. Intususseption--two and a half year old with really bad intermittend abdominal pain caused by the telecoping of one part of bowel into another, treated with an air enema, causing him to fart the rest of the night when he wasn't being a terrible two, "NO!" And then this morning, "I want to go home! I'll be okay."

4. Seizures and half a brain missing--sort of amazing that you can actually survive. She literally is missing at least a third of her brain. Called proencephaly and caused by an in utero stroke of one of the major blood vessels that supply the brain. Family recently immigrated from Iran via Pakistan and very concerned about her increased seizure activity. That was the majority of my night-time calls: "She's having a seizure. She's having another seizure." She has seizures all night.

5. Stridor--9 year old guy who was born at 23 weeks (that's the cut-off for survival usually, he was also a triplet, one of the triplet's died at birth and the other is living and normal developmentally; he weighed about a pound at birth). He has been breathing through a tracheostomy since birth and he just got it out last week. Came in with some difficulty clearing secretions.

And tomorrow I'll get my Anabell back. She comes back because the home where she went didn't feed her the right thing and she got an infection. I visited her before I came home; she is just at cute as ever. Chubby little cheeks.

One of the patients on the other teams is about to die any day. We're all sort of on alert. He is a year and a half and has been brain dead since he had 30 minutes of no oxygen to his brain when he was two years old. Parents have decided to not recuscitate him when he stops breathing. All night his nurse was staring at him to see if he kept breathing. This morning the attending was going over what to do when someone dies on your service. I guess you listen to the heart for a minute to make sure it really has stopped beating, then you listen to the lungs and do a quick pulse check then call the nurse for all the paperwork and details. Gosh. The things you never thought you'd have to learn. This little guy's life has been pretty awful, though. Every asks me if it's hard when kids die. It's hard when it's senseless or they are healthy. It's always hard. I guess sometimes you just see that it's the right thing in the end. It's hardest when there is no thinking that it is right.

There is another baby on another team that is the boy described above only a year earlier in his course. He is two months old. The victum of severe and ongoing child abuse with multiple rib fractures, skull fractures, bleed, retinal hemohorrages, etc. inflicted by his parents at multiple points when they were high on methamphetamine. He is brain dead also and parents are always at the bedside. They want to withdraw care. Which is probably the most humane thing to do at this point. Still hard to think of what could have been...what should have been.

Beach Chair Needed

Wrote the following letter to my new advisee (who is just starting college) through a scholarship that I received out of high school. She is just at the beginning of where I am now. Makes me think of what I should tell her. It is a long long hard road and I'm not even finished yet. I think of the moments that have been turning points for me and the times when adults let me see into their lives.

My pediatrician told me once that he loved coming to work every day. Every day.

One of my professors in undergrad followed his bliss and found daily happiness in teaching literature. Daily.

Part of it is paying attention to what clicks most with you...and part of it is attitude of letting yourself enjoy it. At least that's what I'm working on now.

I have today AND tomorrow off!! Yipee. I have spent this morning doing all sorts of things that I've let slip for the past two months. And basically just lounging around in between. I'm going to head to the beach in a bit. That reminds me. I should get a beach chair at some point. Maybe one of those backpack kind that I see everyone carrying as they walk toward the beach.

It's beautiful here today. Hope your day is as well.


"I got to be an advisor by being an ex-scholar. I received the scholarship all through college and then for three of my four years at medical school. It was a wonderful gift and I continue to grow to appreciate it...as I'm sure you will over the coming years.

I wasn't sure I wanted to be a doctor right out of high school so I just took school/learning one step at a time and tried to pay attention to what I enjoyed and what I thought would get me to a career that I could enjoy for the rest of my life.

In college I knew I had room to still stretch myself after that...and med school sure did it. But you should just take things as they come and do your best at every step of the way. Doing your best always opens doors.

I recommend making close connections with professors up front since you will probalby eventually need letters of recommendation from them. Just be interested. Ask thoughtful questions and, above all, get help as soon as you think you even might need it. Tutors and professors are there to help you learn so you should take full advantage of all your resources.

And have some fun. This first year is an adjustment in many ways. Hang in there. Remember where you're from, but don't be afraid to jump into where you are going, either.

Keep in touch! I'll be anxious to hear how things develop for you over the coming months and years. And let me know if I can help in anyway.

Kindly,

S."

She Loved Watermelon

For some reason I just found your comment on the post about my horse dying. I still think about her a lot. It is strange, and sounds funny, but the first time I think that I loved someone outside my family was her. I remember one time we were riding along the beach and she got dizzy from running the waves and lost her balance. She fell and I fell off and she ran back to the trailor across a really busy road. I ran after her and was so relieved to find her back at the trailor perfectly fine...just a little rattled. Lots of stories like that about she and I. I still miss her a lot. She was the companion of my childhood and youth.

She also liked peanut butter sandwiches and oatmeal raisin cookies. And she had a favorite scratch spot under her belly that would make her stretch out her neck and wiggle her lip.

Good Call

Call last night was...fine. My senior was wonderful and even took my pager for the afternoon so I could get some down time. I found the "healing garden" out behind the hospital and hung out in the sun for a while to recollect myself.

And my patients who have been there forever were supposed to get discharged this afternoon. Literally forever. One of them is almost a year old and has been there since she was two days old. Forever. She just got transferred across the street at a inpatient care facility. I visited her new room. It was actually unexpectedly sad to see her go. But her viagra is doing wonders for her pulmonary hypertension...she's been stable on room air for a week now!

Interesting new patients too:
1. 15 month old with ataxia (dizzy, drunken sailor walk), likely cerebellar (brain balance/coordination center) post infection inflammation
2. One month old Acute life threatening event (not so different, turned out to be reflux, but I got to spend a lot of time with the parents and do some teaching that I think will really change the next five months for them
3. Three month old with likely pertussis (get your kids vaccinated...it's out there and can cause really horrible pneumonia)
4. 2.5 year old with orbital cellulitis

And, you'll notice, only four (I cap at six), which is nice.

And I got to sleep for four uninterruted hours...practically unheard of.

So I got to run some errands after I left (finally got out on time at noon) and then took a nap then went for a run along the beach and watched the sunset while I did situps. Everyone gathers at sunset and watches it go all the way down then meanders off when it sinks below the horizon.

Trust and Thunderstorms

The little girl and little boy were both far away from home. They met one day on the beach under the sun in this land that was familiar to him, but completely new to her. He showed her the best waves and how to chase the birds. They laughed together one day they outran a thunderstorm chasing after them. He took her by the hand and told her to "Hurry!" She could tell then that he didn't want anything to hurt her. He didn't want anything bad to happen to her.

While they spend the next years playing together in the sand, they began to build a sandcastle together. They put up steeples and moats and flags and small rocks for paths. Spending more time together, the castle got more and more elaborate, and stronger and stronger. It was becoming something really special. And people were starting to take notice.

But after a while the little boy seemed to not be as intersted in their sand castle. He met other little boys and they ran around the beach together, throwing rocks and causing trouble. Often they would run so far down the beach that she couldn't see him anymore.

The waves were always there. Their castle was close to the where they would come up when the tide was in. When they had both been tending the castle, it was easy to keep up with the waves destruction. They would take it as a challenge to build something bigger and better where the waves had knocked that part down.

But now that she was often alone at the castle, it was more difficult. Perhaps if she'd given it all of her time, she might have been able to keep up. But it just wasn't as fun without him. And she would spend those hours wondering where he'd gone to this time as the waves lapped at the foundations of their castle.

He started to be gone more and more. And she neglected the castle more and more. Now it was not only torn down by the salty waves, but also by the salty tears she cried when he left her there alone.

One days she went for a walk down the beach, leaving the castle for a while. She found friends of her own who made her feel a little happier. But she missed him. And went back to the castle to look for him again.

When it came into view, she could see him there. But he wasn't alone. And he wasn't with the other little boys. He was with a little dark haired girl. And as she saw them together, they kicked the castle down, laughing. They rolled in the sand that had been their castle. They kicked down the little flags they'd found together. They scattered the rocks. They coaxed the waves to come closer and play with their hands as they slapped at the sides of the castle. It took them only minutes to destroy what they had taken years to build together.

The little girl just watched. Her heart was breaking. It was all she could do to function. It was all she could do to sit just out of reach of the waves to keep them from taking her away, too. She sat there for a very long time, long after they'd run off together down the beach. He didn't even look back at her when they left. As they were leaving, he saw him comforting her as she cried about something. He saw him helping her move her beach towel to a new place. He saw her spending nights and days talking to her. He saw him invite her to where their castle had been. She tried not to look but it was as if she needed to see, despite the crumbling she continued to feel inside.

When she ran into him on the beach, even if he was alone, it was all she could do to not cry. Sometimes they'd start to rebuild a pile of sand together, with vauge dreams of another castle, maybe even stronger and better this time. But when she'd go away for a while, she'd come back to find his footprints there, and they were not alone, and the castles were all kicked over again.

She got tired of rebuilding them. She told him to stop trying if he was just going to kick it over again.

He seemed to want to keep trying, and they started again. This time the castle got to the largest it had been since he had destroyed it with his other girlfriend. They were spending more time together. By this time they'd moved far apart and it was harder to find time to build their castle together. But they were working at it. She was struggling more than she'd expected. After seeing her work and effort destroyed so many times, it was hard to even put in the time it took to build it up one more time. But she struggled to do it. She struggled to build the castle and she struggled to forgive him for destroying it so many times.

She was still struggling a lot when she found him one day causually walking down the beach with the dark haired girl. She saw them headed for their castle, already a shadow of what it had once been. But he didn't see it. He was too busy laughing with the dark haired girl. It wasn't often that he laughed like that with her anymore.

And they walked right over it. The dark haired girl looked back at her, and at the pile of sand, and she laughed. She took the little boy's hand and kept pulling him away. And he kept going with her.

And the little girl walked up to their castle that was once again just a pile of sand. She didn't have the energy to build it again alone. Another thunderstorm came as she sat there crying and thinking about her unfaithful friend. The lightning struck near her as the raindrops mixed with her tears. Together, the drops flattened the rest of the castle. And she hurt.

Kaboom

I guess I'm not the only one struggling through these first few months of residency. I had dinner with two of the other med-peds interns and one of the OB second year residents tonight. All we could talk about is work because that's all we do. Sounds like my CCU months will be worse than peds: 5am to 7pm every day and then covering all the sickest patients in the hospital while taking admissions on call nights. It seems like patient care must disentegrate at some point. All they can hope to do, they said, is keep everyone alive until the morning when help shows up. Great.

But at least we have each other. We can decompress and laugh about things. One of the interns was doing his first presentation to the attending and during the vitals, he started to look glazed over and just fell forward...straight onto the attending. He'd fainted on the floor of the MICU. With a critical care attending on one side, three nurses trying to get a blood pressure and finger stick and the other intern holding his head. Turned out he's just gotten nervous and vasovagaled (basically locked his knees and all the blood pooled in this feet/legs and down he went). He was okay. But the attending wanted to make sure it didn't happen again so made the other intern push him around in a wheelchair for the next two hours of rounds that morning. I can't imagine!

I've nearly gone down several times in the OR as a med student. With the gown and the mask and the never having time to hydrate or eat and feeling nervous and just standing there not pumping blood back up to your brain and everything. I even almost fainted twice on anesthesia. But never on the floor. I shouldn't talk, though. It could just happen. At least I'll know I won't be the only one. Nor the first.

A Day Off

A day off after working thirteen days straight is a beautiful beautiful thing.

One of my ex-boyfriends used to say that Sunday evening was the worse time of the week because the weekend was over and you had the whole week ahead of you. Maybe for Monday through Friday stuff. But I'm enjoying my whole day off and not worrying about what is waiting when I get back to work.

I ran to the gym this morning. Did my lifting and stretching then walked back home along the beach. Then have been catching up on the rest of my life. Paid bills (2/3 of which were late, oh well), took a nap, did a little on-line shopping for next month when I can't wear scrubs to work half the time.

Tonight I'm heading to one of the other med-peds interns' house for a gathering for the four of us. And my new goal is to get in bed by 9pm which will give me eight hours of sleep and maybe make me not be so sleep deprived.

And next weekend I have Sunday and Monday off--two in a row! Bliss!

Five to Seven Minutes

Every four to six months I have to (slash get to) visit jewelry stores. This month it is definitely "have to." I get my jewelry cleaned and checked so that if a stone ever falls out the store will replace it free of charge. Plus it looks so pretty after it's been cleaned.

Today it was not so fun. I had to go to a new jewelry store that the jeweler in Nati recommended where they wanted the bracelet we bought there checked. I should have known it would be difficult when the sign on the huge two story building said "Largest Selection of Engagement Rings!" with a 10 foot engagement ring logo behind it.

I park, and walk in, cranky and exhausted (basically status quo lately) and am greeted by a super perky woman standing at a podium dressed in some sort of Hawaiian theme clothing, "Welcome back to Robbins' Jewelers!!! How can I help you?!?" Oh my goodness. "I just want my bracelet checked." She ushers me efficiently to Customer Service where they whisk off my bracelet and check my paper work. "It will take about five to seven minutes. Feel free to look around or wait in the lounge!" Okay.

I choose incorrectly and wander around. The sign didn't lie. There are hundreds if not thousands of styles of engagement rings. I like the ones with the round diamonds and pattern on the bands. There is a couple getting married in three weeks just picking up her engagement ring. She is afraid to touch it is so beautiful. Two of the clerks are ooing and ahing and encouraging her to wear it, assuring her that it can be cleaned before the wedding and look just as good as it does now.

There is a couple where the woman is much younger than the man and you can tell that he worships the ground she walks on.

There's a couple casually affectionate with each other, supporting the notion that marriage happens in the days and years before and after the wedding more than it does on the actual day.

And there are others. Only happy couples. Seriously. I am surrounded by happy couples and perky saleswoman dressed in variations of Hawaiian print.

I want to be happy for them, but I catch myself almost crying as I am only about a third of the way through the huge displays of rings. I hurry up back to the front and lift up my head and try to think of something else. Five to seven minutes can't pass soon enough.

As I'm waiting, one of the sales women offers me, "water, soda, or tea?!?" Last thing I had to drink was hours ago when I snuck five seconds away from work and ducked into the "Nourishment Room" for a Styrofoam cup of fruit punch gatorade (which I don't like) and graham crackers and one of the little cups of peanut butter that has so many preservatives in it that it doesn't need to be refrigerated. That was lunch. So, "Yes, I'd love some water." She brings me a bottle promptly. "Let me know if you'd like anything else!" She emphasized the "anything" and looks me right in the eye genuinely.

I can hardly even take normal human kindness at this point. And it takes lots of effort to respond with even a fraction of the courtesy they show me. This is not natural for me. Fortunately, I am naturally nice enough that it is default behavior most of the time, even when I am tired. But now I know there comes a point of exhaustion where even that leaves and I just become flat and functional and robotic. I don't like it much at all.

At last the five to seven minutes are up and I get my bracelet returned to me approved and sparkling clean. "Can we do anything else for you?!?" "Not today," I smile back and try to muster some emotion. Problem is, it might be tears again, so I can't let it get too deep, not knowing what will pop up.

Even With a Day Off

Ninety hours last week.

Replaceable

Charlie is a butthead. So I'm sitting on the couch watching the end of "Father of the Bride" and I smell something. Once it reaches my consciousness I know what it is immediately. Not only did he hairball barf on the carpet twice (one of which was there before P. left and she didn't clean it up), he also decided that it would be a good message to me to poop not fifteen feet behind me in plain view (and smell). I got mad and swatted him. Then opened the door hoping he'd walk out and get hit by traffic. He did go out, but they I felt just a little bad...just barely enough to chase him back in. Maybe it will stop him from pooping next time. Not likely, but I tried the nice approach and it didn't work either.

Lots of people are outside having fun at something right now. I wish I were having fun. I don't so much remember how. I feel all bitter inside. I don't like feeling that way. I used to think this was the perfect place to live and now I just keep finding things wrong with it...and everything else in my life. I think I am already burnt out.

Did you know there are four stages to burnout? I can only remember the first and last: over-enthusiasm and burnout. The others are a blur as you experience them, too. Maybe that's why I don't remember them. I don't think it would be so bad if I actually felt like I were having an influence on anyone. Right now the only people I feel like I affect are (maybe) the third year students. Maybe. And even one of them the other day asked me who evaluates them. So I asked my senior. She and the attendings evaluate them. I don't know why I thought I would have any input. I don't have input into anything else.

That's why I think I'm replaceable. It's just a signature. We sign out. One signature or resident to call is just as good as another. And we have so much to do in so little time that we can't even sit and do anything thoroughly. I had a little time to sit with the parents of a little girl with a bad rash today and then I had to leave because I got a page that a nurse needed preauthorization for a insurance company of a patient I was discharging on my cross cover. I was lost in 30 minutes of insurance phone tree only to be told twice that I'd called the wrong number and to ultimately find out that the preauthorization department is closed on the weekend. So this family has to pay out of pocket (if they even can) for a medicine that can stop their five year old boy from having a seizure if he starts. Kind of an important medicine. Kind of should have at least one person in the office to let people get it if they need it on the weekends. Well, at least we know that seizures only happen on Monday through Friday.

My big sib gave me some advice, "Don't bitch." He said there is too much bitching around the hospital, especially on peds and not to add to it. I agree with that in principle. I don't like to add to the negative atmosphere, but there comes a time when you have to make some noise to be heard. Bitching to fellow residents is one thing. Raising concerns about systemic problems is another. I don't think any residency is easy, but I honestly think this one could use a lot of work. It's set up to overwork residents and frustrate patients' families with the inevitable mixed messages. The system was way better in 'Nati. Even at the U. And that is pathetic.

We don't even see the patients with an attending. We see them with the senior resident. The attendings come around randomly later with the fellows and leave notes which are really elaborate "to do" lists for us to find in the charts and carry out orders. This is not a great way to teach us independent thinking.

I am frustrated. And tired. But at least no longer hungry. And I have tomorrow off.

Frustrating and Long Call

Yesterday and last night and this morning seemed to drag on forever. Partially because they did.

The whole structure of the admitting team and call at the hospital here is pretty taxing and inhumane. Plus the patients and families aren't usually even happy so you feel like it's all sort of for not as much as it could be for. (Keep in mind I've now been up for 34 hours straight as you read this and let that help explain the incomprehension and frusteration.)

So we don't start admitting as the call team until 6pm and then we admit all night until 6am the following morning. I got five patients all spaced out enough to keep me up all night. Plus my old patients. One of whom is having horrible headaches as I'm trying to be patient as the med student takes the eternily detailed history from the 17 year old girl with the nonspecific abdominal pain. Another who is yelling "MAMA" at the top of his crying voice over and over because his mom has gone home to take a shower. The nurses finally close the door to his room.

But the nurses themselves get loud also. They start talking again about how many hours they work at a time (12) and how it's so awful to work three days in a row. "I worked a five once three years ago," one of them brags, "Never again, I was going crazy by the end of it." I try to tune them out. I have worked now for four straight weeks with one day off in the middle. And those days are nearly all longer than 12 hours. Some, like last night, are 32 hours.

Plus I still have a lot of unaddressed anger toward nurses because of what Michael did. I can just picture that little bitch that he slept in with those nurses. She was a night nurse. Chatting and cackling and gossiping and complaining and flirting with my boyfriend...or calling him...or sleeping with him...or going out with him while I was home alone in the apartment we shared...I'm beginning to wonder if I'll ever be able to get over it. There is one who even looks a little like her and I have to try to over compensate so I don't glare at her too much and treat her poorly.

I was so tired after being up all night and I was just pushing through to get out on time at noon. And for once I had all my stuff tied up enough to check out to the cross cover person. But then at 12:20, as I'm already annoyed that people are wasting my time and not letting me get home, I get a page that one of the specialist attendings for my 9 year old girl with a resolving sandpaper rash with finger desquamation (all the skin pealing off the tips of her finger). She wants to have the whole team gather to go over a physical exam on my patient because we'd missed some key things for the diagnosis of this disease in which she is the national expert. "Are you fucking kidding me?!?" I sat to myself. Exhaustion and frusteration diminish me to profanity. I called my senior who says, yes, I do have to go. Even though we're post call. Even though I was ready to leave 40 minute ago. Even though I have been up all night. Even though this attending might keep up for an extra hour.

Yes, we missed things on the physical exam, the little girl came in at 4 am and she was completely exhausted. She could barely keep her eyes open, let alone get up and talk about how she has been walking as the attending was now demonstrating. Yes, we missed it, and in the same situation I would choose to miss it again. She was not in acute danger. The attending had already micromanaged to the point where we weren't going to get to make any read decisions about her diagnosis or treatment anyway. We were really just a glorified babysitting service for her.

When she finally finishes, the nurse of my screaming patient calls and says mom has a bunch of questions and she's going to "escalate" if I don't come talk to her. Are you kidding? Who comes to talk to me when I decomensate as I am about to. I already almost broke into tears inte the middle of the pod with the med students. So, on my way out the door I talk to her, and she's totally calm and reasonable...she just feels helpless and wants to have some control and input into the care of her 3.5 year old boy with only 10 cm of small bowel. That's totally understandable. And why do the systems issues at this hospital make parents feel like they have to fight for what they want. What has created this somewhat advisarial atmosphere? We all want the same thing, don't we? Good Gosh. Systems of management that make you feel that way are crap. It is just so frusterating.

And what does she say when I get to her room? "I thought you'd be gone by now. You look tired." I am tired.

Then one of the attendings sees me finally leaving the hospital at 1:30, "Getting out post call at 1:30--no good." I'm not sure if it's a reprimand or just something to say. Like it's somehow my fault that I'm leaving at 1:30. It's like the collective awareness of the hospital objective and goals and call time regulations is missing. The same attending who showed us all the physical exam at 12:40, then walked out of the room and tried to send two of the med students down to the lab to see a smear of spun down urine and report back to her. I just bowed my head lower over the orders she was having me right to hide the disgust and disbelief on my face. Was this really happening? Does the systems have that little awareness of the pieces that compose it? Finally, our senior stood up for them and said they were post call and would not be able to go right then. "Oh. Well, report back Monday, then." She sounded slightly dissapointed.

This is a time of the new work-hour rules in medical training programs and all the attendings did not have them so many of them have this sort of unspoken aura of, "Back when I trained we worked harder than you all; and I think it's ridiculous that you can't stay all day post call like we used to have to." Whatever.

Plus I feel overall completely underappreciated and superfluous to the whole system. I cannot make any changes to plans without running it by at least three people. It stifles my ability to formulate management plans on my own. When it feels like I am nothing more than a convenient order-writer for what other people have been able to think about and discuss and learn. It feels like it could run very well, if not even better, without us. It's not a good feeling.

Finally, I got out of there, but had to pick up my first paycheck (yep paid only once per month) and they still haven't figured out how to do the direct deposit. So I have to stop at the other hosptial on my way home. I am so tired that everytime there is a red light I close my eyes and nearly fall asleep. My reflexes are noticably slowed and I am trying to be extra deliberate so I don't get in a car wreck.

I figured out how much I make at day, less than $100, and if hourly then it is just about minimum wage. We make less than any other program in the country that I know of. And it costs more than nearly anywhere else to live here. Something is wrong with this picture.